Episode 161: The Encouraged Suicide of Conrad Roy by Michelle Carter
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Article Authors: Corrin Pelini, DO, Michael Cummings, MD, David Puder, MD
Corrin Pelini, D.O., Michael Cummings, M.D., David Puder, M.D. have no conflicts of interest to report.
“I Love You, Now Die”: Details of the Documentary
This 2014 case involves Michelle Carter and Conrad Roy, both teenagers at the time in Massachusetts. They met on vacation and a very intense relationship ensued. Their relationship was almost entirely virtual; they met in person only a handful of times. Thousands of text messages were exchanged between Roy and Carter over the next few years. Roy began confiding in Carter about thoughts of suicide. As time went on, she began encouraging him to go through with it: “Drink bleach. Hang yourself. Jump off a building, stab yourself, idk. There’s a lot of ways.” “If you want it as bad as you say you do, it’s time to do it today.” Eventually, Conrad Roy put a small combustion engine in the backseat of his truck and died by carbon monoxide poisoning in a Kmart parking lot. Phone records show he spoke to Michelle twice while he was there. A later text to her friend indicated what was said during the calls: “Sam, his death is my fault. Like, honestly, I could have stopped him. I was on the phone with him and he got out of the car because it was working and he got scared and I fucking told him to get back in.”
The state of Massachusetts investigated the suicide and filed a charge of involuntary manslaughter against Michelle. It went to trial and the judge ruled that she was guilty; she spent 15 months in jail (she was released early for good behavior) and has a five-year probation.
Both Roy and Carter had a history of mental illness. Roy suffered from depression and attempted suicide by intentional acetaminophen overdose, resulting in a hospitalization, predating his involvement with Michelle. He was prescribed citalopram (Celexa) at the time of his death. Carter had a history of an eating disorder. She had been prescribed fluoxetine (Prozac) and then citalopram (Celexa); she was taking Celexa at the time of Conrad’s death.
Peter Breggin’s Defense
Dr. Peter Breggin is a psychiatrist that served as an expert witness on behalf of Defendant Michelle Carter. He has been involved in numerous similar cases where he defends individuals who are charged with acts committed while taking psychotropics, most often selective serotonin reuptake inhibitors (SSRIs). In his testimony, he asserted the “dangerous” mechanism of action of SSRIs: after use, they cause serotonin to become depleted in the brain. “[The brain] stops producing it, increases removal processes [by hypertrophy of the receptor], and cutting back on receptors.” He argues that citalopram (Celexa), the SSRI Michelle Carter was taking, caused “involuntary intoxication” and she should not be liable for her actions. “She was grandiose, reckless, not thinking about criminal responsibility. She was unable to form intent because she was so grandiose.” He alleged the antidepressant induced a hypomanic state which impaired her judgment.
Of note, Dr. Breggin’s diagnostic evaluation of Michelle Carter was determined without ever interviewing her. His information was gathered by interviews of her family and peers, as well as reading through her medical records and text messages. As Dr. Cummings stated in this episode, the American Psychiatric Association (APA) deems diagnosis without examining the individual to be unethical.
Dr. Cummings refutes Dr. Breggin’s defense in that there is no evidence that Celexa causes an acute intoxication. Rather, the literature describes adverse effects, such as antidepressant-induced jitteriness/anxiety syndrome in the early stages of treatment (Sinclair et al., 2009). It also has the potential to cause rapid cycling in those with bipolar disorder (Ghaemi et al., 2003); however, there is no evidence Carter had a diagnosis of bipolar disorder. Dr. Cummings also disputes his description of SSRI antidepressant mechanism of action. He described that the medications do not deplete serotonin, rather they regulate the concentration of serotonin and transporters in the brain to reach homeostasis.
Peter Breggin’s Other Statements and Our Counters
Dr. Breggin shares his stance on avoiding the use of psychotropic medications via articles, books, trial testimonies, and video presentations. A video labeled, “The Dangers of Psychotropic Medications,” was posted to the app TikTok. Some of the statements he made about various medications include: stimulants shrink brain tissue; nonbenzodiazepine sedatives shorten lifespan; benzodiazepines shrink brain tissue; antipsychotics “wreck” the basal ganglia, cause a “chemical lobotomy,” and shorten lifespan; and mood stabilizers cause memory issues and learning difficulties.
Contrary to Dr. Breggin’s statement, psychotropic agents have been shown to have neurotrophic & neuroprotective effects. Mood stabilizers, antidepressants, and antipsychotics have been found to upregulate factors such as BDNF (Hunsberger et al., 2009). Imaging has also shown that these medications increase the volume and density of brain tissue (Hunsberger et al., 2009). Dr. Cummings also describes that the decrease in lifespan in those using antipsychotics is not due to the medication, but the effects of the illness itself.
Also in these videos, Dr. Breggin stated that prescribers are unaware of how dangerous psychotropic medications are because they get all their information from drug companies. Although some physicians may meet with drug representatives and be persuaded to prescribe those medications, this is not always the case. Many physicians use evidence-based decision-making, cost of medication, and side-effect profiles to decide upon which medication to prescribe, if one should be prescribed at all. Doctors are not paid more if they prescribe newer and more expensive medication, actually it can take more time filling out dreaded prior authorizations.
Physician Assisted Suicide in Canada
In June 2016, Canada made it legal for adults to request medical assistance in dying (MAID). In March 2021, revisions to the legislation were made to specify who is eligible to obtain assistance and revise the process. According to the most recent legislation, physicians and nurse practitioners are permitted to provide MAID and other healthcare professionals can assist the process.
There are two forms that are allowed to take place: directly administering a lethal substance or prescribing a lethal medication that the individual takes themselves. Specific drugs are permitted to be used and are outlined by provinces/territories.
The legislation states that if mental illness is the only medical condition an individual has that is causing them to consider MAID, they are not eligible to seek assistance in dying at this time. This will remain in effect until 2023, giving more time to consider how to safely broach this issue.
Specific protocols are outlined by the Canadian government to regulate the process of requesting MAID. It involves multiple medical assessments, submitting a signed written request, an independent witness, and final consent.
All the above information was obtained from Canada.ca, the official website of the Government of Canada.
The Use of Antidepressants in Bipolar Patients
There is extensive literature supporting caution in using antidepressant medication in patients with bipolar disorder. There is an identified risk of inducing mood-cycling in those taking antidepressants (Ghaemi et al., 2003). They also have not been shown to be any more effective than mood stabilizers in treatment of bipolar disorder. There is no evidence they decrease suicidality or prevent depressive relapses, unlike mood stabilizers (Ghaemi et al., 2003). Regarding the use of antidepressant therapy as adjunctive treatment, it has not been associated with increased efficacy (Sachs et al., 2007). Ideally we should stay away from SSRI and SNRI medications for patients with bipolar, however it is not clear from any evidence that a diagnosis was clear from the documentary.
Conclusion
As psychiatrists listening to this story, it is especially tragic that proper treatment was not given. A partial program would have potentially saved his life or helped improve her hopelessness regarding him changing. There are tons of treatments that were likely not tried, including intensive psychotherapy, ketamine, TMS, or ECT. We discussed how the decision to take one's life is so large that being depressed would remove capacity to make such a decision. We have treated many hopeless people who, after effective treatment, find meaningful work and relationships and look back at their period of hopelessness with new insight into its temporary nature. Unfortunately, Michelle Carter was naive in her understanding of mental illness and if she had years of treating depressed and hopeless patients, she might have had unshaking hope that he could have changed.
Resources:
Hunsberger J, Austin DR, Henter ID, Chen G. The neurotrophic and neuroprotective effects of psychotropic agents. Dialogues Clin Neurosci. 2009;11(3):333-48. doi: 10.31887/DCNS.2009.11.3/jhunsberger. PMID: 19877500; PMCID: PMC2804881.
Sinclair LI, Christmas DM, Hood SD, Potokar JP, Robertson A, Isaac A, Srivastava S, Nutt DJ, Davies SJ. Antidepressant-induced jitteriness/anxiety syndrome: systematic review. Br J Psychiatry. 2009 Jun;194(6):483-90. doi: 10.1192/bjp.bp.107.048371. PMID: 19478285.
Sachs GS, Nierenberg AA, Calabrese JR, Marangell LB, Wisniewski SR, Gyulai L, Friedman ES, Bowden CL, Fossey MD, Ostacher MJ, Ketter TA, Patel J, Hauser P, Rapport D, Martinez JM, Allen MH, Miklowitz DJ, Otto MW, Dennehy EB, Thase ME. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med. 2007 Apr 26;356(17):1711-22. doi: 10.1056/NEJMoa064135. Epub 2007 Mar 28. PMID: 17392295.
Ghaemi SN, Hsu DJ, Soldani F, Goodwin FK. Antidepressants in bipolar disorder: the case for caution. Bipolar Disord. 2003 Dec;5(6):421-33. doi: 10.1046/j.1399-5618.2003.00074.x. PMID: 14636365.
Siesser WB, Sachs BD, Ramsey AJ, Sotnikova TD, Beaulieu JM, Zhang X, Caron MG, Gainetdinov RR. Chronic SSRI treatment exacerbates serotonin deficiency in humanized Tph2 mutant mice. ACS Chem Neurosci. 2013 Jan 16;4(1):84-8. doi: 10.1021/cn300127h. Epub 2012 Oct 1. PMID: 23336047; PMCID: PMC3547473.
Popa D, Cerdan J, Repérant C, Guiard BP, Guilloux JP, David DJ, Gardier AM. A longitudinal study of 5-HT outflow during chronic fluoxetine treatment using a new technique of chronic microdialysis in a highly emotional mouse strain. Eur J Pharmacol. 2010 Feb 25;628(1-3):83-90. doi: 10.1016/j.ejphar.2009.11.037. Epub 2009 Nov 26. PMID: 19944680.
R. v McNaughten: https://acrobat.adobe.com/link/review?uri=urn:aaid:scds:US:48515aaf-b3a2-38d2-81e4-ad0b1fa5120d
Montana v. Egelhoff: https://acrobat.adobe.com/link/review?uri=urn:aaid:scds:US:291f688b-7578-3dbf-a9d9-bea1e228e98e
Dr. Breggin on the Dangers of Psychotropic Medications:
Canada, Health. “Government of Canada.” Canada.ca, / Gouvernement Du Canada, 26 July 2022, https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html#a1.